Quench Accident, Incident, and Near-Miss Reporting Form *(For Manager Use Only)
NOTE FOR VEHICLE INCIDENTS: only complete this form if a Quench employee is injured as a result of the incident. Otherwise complete the Vehicle Accident Form.
Section 1: Who was involved in the incident?
Provide the details of the Quench employee was was involved in the incident or reported the near-miss.
Name of the employee involved or injured:
*
First Name
Last Name
Employee's Job Title
*
Employee's Work Location (Branch, DC, Office)
*
Employee's Department?
Field Service
Supply Chain
Other
Employee's Quench Email
*
example@example.com
RSD
Please Select
Beatty, Robert
Desmond, Richard
Healy, Jason
Perez, David Kenji
Perrine, Troy
Peterson, Daryle
Thompson, Austin
Section 2: Who is reporting the incident?
Your name:
*
First Name
Last Name
Your Job Title
*
Your Quench email address:
*
example@quenchwater.com
Section 3: Details about the incident or near-miss.
Reporting Date
*
-
Month
-
Day
Year
Date
Date of Incident
*
-
Month
-
Day
Year
Date
Time of Incident
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Vehicle VIN Number (if a Quench truck was involved)
Location of Incident
*
Details of where the accident/incident took place
*
Describe how the accident/incident occurred (give a cause where possible)
*
Details of Accident/Injury
*
Was the Quench employee involved in the accident/incident wearing PPE?
*
Yes
No
N/A
Did the Quench employee involved in the incident/accident have all Quench required PPE on available on their truck?
*
Yes
No
N/A
Was the Quench employee involved in the incident/accident using customer or location supplied PPE?
Yes
No
N/A
Pictures of Accident/Incident
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Section 4: Details of any witnesses to the event.
Name of Witness
Non-Quench Employee
Witness Contact Phone Number
Witness Email
example@example.com
Witness Occupation/Role:
Witness Employer (if Quench Customer)
Witness Statement
Attach Copy of Witness Statement (if applicable)
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Section 5: Confirmation of Information
To be completed by the person filling out this Jotform: I confirm that the information I have provided in this form to my employer, Quench USA Inc., is true and accurate to the best of my knowledge.
Name
*
First Name
Last Name
Signature
*
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